Integrating Emotionally Focused Therapy

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The Family Journal: Counseling and Therapy for Couples and Families 2015, Vol. 23(4) 346-357 Integrating Emotionally Focused Therapy, ª The Author(s) 2015 Reprints and permission: Self-Compassion, and Compassion-Focused sagepub.com/journalsPermissions.nav DOI: 10.1177/1066480715601676 Therapy to Assist Shame-Prone Couples tfj.sagepub.com Who Have Experienced Trauma

Mark Karris1 and Benjamin E. Caldwell1

Abstract Emotionally focused therapy (EFT) for couples in which one or both partners have a history of trauma and are shame prone presents unique challenges that can potentially impede the therapeutic process. Neff’s conceptualization of self-compassion and research has demonstrated the benefits of self-compassion for both oneself and interpersonally. Gilbert’s compassion-focused therapy (CFT; 2010) is an evidence-based, integrative approach that specifically works with trauma and chronic consequences of affect dysregulation and shame. This article reviews the empirical research on EFT, self-compassion, and CFT and includes a brief review of trauma and shame. This article also discusses various ways in which Neff’s conceptualization of self-compassion and Gilbert’s CFT can be integrated into EFT for the benefit of both the EFT therapist and couples taken over by trauma and shame.

Keywords emotionally focused therapy, self-compassion, trauma, shame, mindfulness, dysregulation, compassion-focused therapy

There has been a recent increase in research regarding self- Emotionally Focused Therapy compassion since Kristin Neff (2003a), a researcher from the University of Texas at Austin, operationalized the concept Although other people are often the source of trauma (e.g., in war, abuse, or assault), it is within safe and significant interper- and created a scale to measure its constructs. A growing body sonal relationships that trauma victims can heal and recover of research indicates that self-compassion is linked to intra- (Herman, 1992; van der Kolk, McFarlane, & Weisaeth, 1996). personal (Gilbert, 2005, 2014; Neff, 2003a; Neff, Kirkpatrick, Relationships are vital for human existence and necessary ‘‘from & Rude, 2007; Neff & McGehee, 2010) and interpersonal cradle to the grave’’ (Bowlby, 1982). Emotional resilience and (Neff & Beretvas, 2013; Neff & Pommier, 2013; Yarnell & a fortified sense of self cannot exist in the absence of relation- Neff, 2013) benefits. Another model with extensive research ships (Mikulincer, 1995), especially in the aftermath of trauma is Gilbert’s compassion-focused therapy (CFT). CFT is a model of psychotherapy that places self-compassion at the (Mikulincer, Shaver, & Horesh, 2006). EFT, which is one of the most empirically supported approaches to couple therapy core of its approach and was developed for individuals with (Lebow, Chambers, Christensen, & Johnson, 2012), takes trauma backgrounds struggling with psychological problems advantage of the healing power and primacy of relationships linked to self-criticism and shame (Gilbert, 2010). This theo- and is currently used as an efficacious treatment approach with retical article will explore the integration of self-compassion couples affected by trauma (S. M. Johnson, 2002, 2004; Macin- and CFT with emotionally focused therapy (EFT; S. M. John- tosh & Johnson, 2008). son, 2002), to assist couples overcome the impact of trauma in EFT is an experiential approach to couples therapy that Sue couples’ therapy. Self-compassion practices and principles will be used for the explicit purpose of regulating negative Johnson and Leslie Greenberg developed in the early 1980s (Greenberg & Johnson, 1986; S. M. Johnson & Greenberg, and constrictive affect with couples to move toward the pre- 1995). EFT emphasizes the emotional attachment bond ferredstrategyofcoregulationof difficult emotional states (Beckes & Coan, 2011; S. M. Johnson, 2004; Sbarra & Hazan, 2008). This article will include an exploration into how self- 1 compassion–based interventions can reduce both couple and Alliant International University, San Diego, CA, USA therapist shame, which is a particular affective state that can Corresponding Author: impede the trauma work essential to EFT (S. M. Johnson & Mark Karris, 13122 Sienna Court San Diego, CA 92129, USA. Williams-Keeler, 1998; Macintosh & Johnson, 2008). Email: [email protected]

Downloaded from tfj.sagepub.com at University of Texas Libraries on June 3, 2016 Karris and Caldwell 347 between couples and is grounded in attachment, humanistic, posttraumatic stress disorder (PTSD; Amir & Kaplan, 1996) systemic, and experiential theories (S. M. Johnson, 2004). Fun- or other subclinical levels of emotion dysregulation. damentally, EFT is an attachment-based model. While Bowlby EFT is gaining traction with regard to being efficacious for (1982) and others (e.g., Ainsworth, Blehar, Waters, & Wall, couples dealing with trauma and who meet criteria for PTSD 1978) applied attachment theory to children, S. M. Johnson and (Greenman & Johnson, 2012; S. M. Johnson, 2004). For Greenberg applied it to couples. Our needs for secure attach- instance, Naaman (2008) demonstrated a significant reduction ment do not change over time, S. M. Johnson and Greenberg in PTSD symptoms using EFT with couples in which the wife argue, but rather are refocused on the romantic partner as the suffered from breast cancer. War veterans had a significant primary attachment figure. EFT focuses on creating a safe and decrease in PTSD symptoms after they engaged in an average secure attachment bond with that partner. of 30 sessions of EFT (Weissman et al., 2011). In another study, Distressed couples typically come into therapy over- EFT successfully decreased PTSD symptoms experienced by 10 whelmed by intense emotions that have the capacity to keep highly distressed couples in which one partner was a survivor of them stuck in a pernicious pattern of negative interactions childhood sexual abuse (MacIntosh & S. M. Johnson, 2008). (S. M. Johnson, 2004). In the process of EFT, emotions that are McLean and Hales (2010) conducted a case study using EFT typically constricted, unprocessed, and hidden from the self with couples in which one partner was terminally ill and the and the partner, such as fear, sadness, loneliness, shame, and other partner had a history of childhood trauma. EFT was shown anxiety, are tenderly and vulnerably brought out into the open to help the couple navigate through the complications of the ter- and shared. As these new vulnerable emotions are experienced minal illness and help lessen the complications of spousal and processed, they can create new healing emotional experi- bereavement. Halchuk, Makinen, and Johnson (2010) showed ences for the couple that transcend the therapy office and con- that EFT was also effective at helping couples heal through the tinue into their everyday lives. Emotions in EFT are considered trauma of infidelity, with sustained forgiveness and trust at the ‘‘music in the dance’’ (S. M. Johnson, 2004, p. 67). When 3-year follow-up. More recently, S. M. Johnson et al. (2013) therapists can help couples change the music (emotions), they demonstrated through an functional magnetic resonance imaging can change the dance (interactions; S. M. Johnson, 2004). (fMRI)-based hand-holding study that EFT can foster a loving The process of change in EFT consists of nine prescribed steps bond that comforts couples and soothes their threatened brain in within three stages, with the overall goal of forming a secure emo- the midst of potentially threatening stimuli, in addition to reduc- tional bond (S. M. Johnson, 2004). Stage I involves an overall ing the perception of or neutralizing previously arousing stimuli. assessment and de-escalation of the couple’s pernicious negative Additionally, EFT’s potential to become a powerful approach to interaction cycle. Stage II involves a shift from the couple’s rigid help couples traverse the trauma of terminal illness has been interactions toward new bonding experiences. Stage III, the final examined using a theoretical lens (Tie & Poulsen, 2013). stage, involves the consolidation of these changes and the integration of new interactions in the couples’ everyday lives. EFT is one of the few empirically validated models for cou- EFT, Trauma, and Shame ples (S. M. Johnson, 2004). In a meta-analysis, S. M. Johnson, Although shame does not affect every person who has experi- Hunsley, Greenberg, and Schindler (1999) showed that approx- enced trauma, it has now been included in the criteria for PTSD imately 90% of couples who completed EFT reported having in the newly published DSM-5 (APA, 2013). Although it is more satisfying relationships than the average no-treatment con- mentioned only by name and not specifically detailed in the trol couple. DSM-5, shame can be one of the most difficult consequences of trauma, particularly when perpetrated maliciously by other human beings (Herman, 2011). According to Herman (2011), when shame becomes a central feature of a victim’s inner EFT and Trauma world, the posttraumatic condition can be thought of as a Trauma involves psychological damage in the midst of intense ‘‘shame disorder’’ (p. 262). Shame can be considered ‘‘the fear, helplessness, and horror, whether through personal or wit- default setting for insidious emotional trauma’’ (Cates, 2014, nessed experience of traumatic events (American Psychiatric p. 45). Shame is considered a key emotion that could exacer- Association [APA], 2013). Trauma causes an inner shift that bate PTSD and is an important emotion for the clinician to alters one’s view of self and the world (S. M. Johnson, 2002). address throughout therapy (Harman & Lee, 2010; La Bash According to the Diagnostic and Statistical Manual of Mental & Papa, 2014; Lee, Scragg, & Turner, 2001). Finally, the Disorders (DSM-5; APA, 2013), trauma may result from various recently designed and effective Trauma Related Shame Inven- forms of abuse, combat, loss of a loved one, violent personal tory, which is a 24-item measurement instrument that assesses assault, and other direct or indirect traumatic events. S. M. John- for shame within the context of trauma, points to the importance son (2002) added that serving in an occupation that frequently of assessing for trauma-related shame (Øktedalen, Hagtvet, places a person in danger or in close proximity to others’ trauma Hoffart, Langkaas, & Smucker, 2014). can also be traumatic. Those who experience intense trauma It is helpful for clinicians to distinguish shame from guilt. may then suffer the affect dysregulation disorder known as Guilt is an emotional and cognitive state experienced after one

Downloaded from tfj.sagepub.com at University of Texas Libraries on June 3, 2016 348 The Family Journal: Counseling and Therapy for Couples and Families 23(4) has done something wrong and is focused on one’s behavior recognized in the West as an important psychological construct and a desire to make amends (Tangney & Dearing, 2002). In (Gillath, Shaver, & Mikulincer, 2005). There are different con- contrast, shame is an individual’s experience that he or she is ceptualizations regarding self-compassion. Goetz, Keltner, and something wrong. Shame-prone people believe that there is Simon-Thomas (2010) emphasized compassionate appraisals something terribly wrong with them and that the core of who and action tendencies, including costs and benefits, while the they are is bad, flawed, or even disgusting (Beck, Rush, Shaw, Dalai Lama (2001) highlights focused attention immersed in & Emery, 1979). Shame proneness is the experience of shame compassion and an intention to alleviate the suffering of others. that continually resides within an individual as opposed to Neff’s (2003a, 2003b) conceptualization of self-compassion situational shame that arises in particular moments (Dearing is derived from Buddhist thought and social psychology. Neff’s & Tangney, 2011). Bradshaw (1988) discussed the negative research has been mostly conducted with her Self-Compassion effects of toxic shame, and noted shame is a ‘‘rupture of the self Scale (Neff, 2003a), which measures dispositional levels with the self’’ (p. 30). Those who experience deep shame of compassion toward oneself. Neff’s breadth of research believe that they are intrinsically flawed, defective, and unlo- provides ample evidence about the correlation between self- vable and can never be good enough for themselves or others compassion and interpersonal and intrapersonal health. This (Efron & Efron, 1989). Shame and the aforementioned intra- body of research highlights the importance of reflecting on its personal consequences of trauma can wreak havoc on relation- development and use for EFT clinicians and clients. Addition- ships (Dorahy et al., 2012; S. M. Johnson, 2002; Lee, 2008). ally, this article will explore Gilbert’s (2005, 2009) CFT, which The ultimate goal of working with shame in EFT is to have the is a form of psychotherapy developed for individuals who are partner who is experiencing shame vulnerably share it with an shame prone, self-critical, and have trauma backgrounds. CFT open and receptive partner and to have the partner respond with interventions and principles will be used to enhance EFT and understanding and soothing to create a new positive cycle of inter- provide practical interventions that can help shame-prone trau- action (S. M. Johnson, 2002). This is accomplished in Stage II of matized couples learn how to self-regulate when coregulation EFT after the couple’s surface conflict has been calmed (‘‘de-esca- with their partner is not a viable option. lation’’ in EFT terms), and the couple is able to see their trauma- Most of the empirical research on self-compassion has been based responses as part of the negative interaction cycle (S. M. correlational using the Self-Compassion Scale (Neff, 2003b), Johnson, 2002). Moving to Stage II, toward optimal coregulation which is a 26-item self-report measure that focuses on the three and the sharing of vulnerable primary emotions, can be difficult to components mentioned earlier (the instrument has six sub- achieve with traumatized couples. EFT with such couples may scales, one for each component and one for each component’s take 30 sessions or more, which is significantly longer than EFT counterpart): self-kindness, self-judgment, common humanity, with nontraumatized populations (S. M. Johnson, 2004). perceived isolation, mindfulness, and overidentification. It can be difficult to de-escalate traumatized couples in Stage Self-kindness involves treating oneself as one would a lov- I of EFT because of the inability of trauma survivors to regulate ing friend in the midst of his or her pain and suffering: with their intense emotional states (S. M. Johnson, 2002; S. M. John- kindness, warmth, and genuine care. This is in contrast to son et al., 2005). Shame is one of the most powerful emotions attacking and being harsh, judgmental, and critical toward one- that can prevent de-escalation and engagement in new corrective self in the midst of a failure or difficult experience (Neff, and healing experiences (S. M. Johnson, 2002; S. M. Johnson & 2003b, 2009). Instead of engaging in self-flagellation, self- Williams-Keeler, 1998; Lee, 2008). This finding is in line with kindness allows people to treat themselves gently and compas- the attachment framework postulated by EFT; for a person to sionately, despite their flaws and foibles. Common humanity is securely attach to another, they must perceive the other as avail- central to self-compassion and recognizes that all human able and receptive, but they must also perceive themselves as beings are flawed, fractured, wounded, broken, and prone to fundamentally deserving of love and safety (S. M. Johnson, make mistakes to some degree (Neff, 2003a). Keeping com- 2004). For example, shame was a major cause in complicating mon humanity in mind during personal failure provides an invi- the EFT process with a couple affected by childhood sexual tation to bring compassion into one’s experience. The converse abuse (Macintosh & Johnson, 2008). When the emotionally dys- of common humanity is the tendency to isolate oneself and feel regulated trauma survivor was triggered by something they per- alone in the midst of distress. Isolation tends to breed self- ceived as threatening from their partner, they became flooded judgment and feelings of disconnection from other human with shame, which triggered the negative cycle. Communication beings (Neff, 2003a, 2003b). Mindfulness is the last component with the partner would then cease, and deep emotional process- of Neff’s self-compassion trinity. Germer (2005) defined mind- ing would come to a halt in the service of containing the trauma fulness as ‘‘awareness of present experience with acceptance’’ survivor’s overwhelming affect. (p. 7). Mindfulness involves being aware of one’s experience and seeing thoughts and feelings as separate from oneself in contrast to overidentifying and fusing with them (Neff, Self-Compassion 2003a). Mindfulness helps keep a balanced view of negative Self-compassion has a rich history in Buddhist concepts and emotions and experiences while cultivating an open and flex- practices (Kornfield & Walsh, 1993) and has only recently been ible perspective (Neff, 2003a).

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Self-Compassion Research and Benefits safeness. The primary focus of CFT is to help clients skillfully access their soothing affect system to experience affiliative Research has indicated that self-compassion is significantly emotions, which enable them to downregulate the threat system correlated with self-report measures of happiness, hopefulness, (Gilbert, 2010). CFT helps clients cultivate compassion toward positive affect, wisdom, motivation, curiosity, engaging in new themselves and others through the safety of the therapeutic experiences, agreeableness, extroversion, and conscientious- relationship, compassion-based experiential exercises, and cul- ness (Neff, 2003b; Neff, Rude, & Kirkpatrick, 2007). Self- tivation of compassion-based insights and skills (Gilbert, 2005, compassion is also correlated with lower levels of depression, 2010). obsessive thinking, neurotic perfectionism, and anxiety (Mac- In CFT, shame can be differentiated between internal shame Beth & Gumley, 2012; Neff, Pisitsungkagarn, & Hseigh, (how we exist in our mind) and external shame (how we exist in 2008; Van Dam, Sheppard, Forsyth, & Earleywine, 2011). the mind of others; Gilbert & Irons, 2005). Internal shame is The interpersonal benefits of self-compassion have recently experienced when a person makes critical judgments or is dis- been examined as well. Neff and Beretvas (2013) found that contented toward oneself. External shame occurs when we self-compassion was associated with greater intimacy and heal- believe that there is condemnation or disapproval in the mind thier interpersonal relating. More specifically, self-reported of other people or fear that other people do not like us or are self-compassion levels were associated with feeling valuable, not happy with us. Both internal and external shame activate content, happy, and able to be authentic with others. Addition- the threat system and have an adaptive evolutionary function ally, people whose partners scored higher in self-compassion for both survival and reproduction (Gilbert, 1989; Gilbert & described them as being significantly more warm, considerate, Irons, 2005). Those with trauma and intense shame can have and affectionate. In contrast, people whose partners were difficulties being compassionate with themselves and experien- lower in self-compassion described them as being more self- cing affiliative emotions (Gilbert, 2009). CFT has shown to be absorbed, detached, and controlling. Using self-compassion effective in helping clients work through the fear of affiliative interventions, such as responding to yourself as you would a emotions and experience self-compassion with greater ease dear friend, can reduce shame and inhibit the activation of the (Lawrence & Lee, 2013). threat system when exposed to shame-activating memories (E. A. Johnson & O’Brien, 2013). There are other interpersonal benefits to having more self- EFT, Self-Compassion, and CFT compassion. For example, self-compassion serves to foster The principles of attachment theory help elucidate why self- trust and equip partners to have more compassionate, mutual compassion may be a useful concept to integrate into EFT. goals in relationships (Crocker & Canevello, 2008). Self- As described earlier, EFT suggests adults in a romantic rela- compassion can help partners take the perspective of their tionship become each other’s primary attachment figure. In loved ones and motivate them to be more forgiving (Neff & such a relationship, it is vital for partners to be able to approach Pommier, 2013). Self-compassion is also linked to partners one other with vulnerability and experience a responsive and being more likely to resolve ruptures in a relationship (Yarnell accepting other to develop and maintain a secure attachment & Neff, 2013). Finally, the brain activity of those experiencing bond. EFT is an experiential model that utilizes therapy to cre- feelings of self-compassion, as revealed through fMRI technol- ate bonding events that involve vulnerability and responsive- ogy, is associated with similar neuronal activity as that of ness (S. M. Johnson, 2004). However, to the degree that feeling empathy for others (Longe et al., 2010). individuals experience themselves as damaged or broken (e.g., the degree that individuals experience shame), it becomes increasingly difficult to approach the partner with openness and CFT vulnerability and to trust that the partner will be accepting. The Gilbert’s CFT (2010) draws on insights from Buddhist prac- exercise of Neff’s self-compassion correlates can help people tices, evolutionary biology, attachment theory, social psychol- become mindful and aware of their fears and feelings of inade- ogy, Jungian psychology, and clinical experience. Gilbert bases quacy and feel comforted knowing that their feeling of shame is his approach on the distinction between three interacting and common to humanity. Offering self-compassion and kindness distinct affect systems (Depue & Morrone-Strupinsky, 2005), to his or her self in the midst of their mistakes allows them which correspond to threat, incentives, or drives and soothing to experience a greater openness to interact with their partner. while triggering feelings of threat, excitement, and soothing And engaging in an accessible, responsive, and engaged man- (Gilbert, 2005). The threat detection system or threat mind ner to their primary attachment relationship is the primary goal evolved for protection and can include emotions such as anxi- of EFT (S. M. Johnson, 2004). ety, anger, disgust as well as behaviors of fight, flight, freeze, EFT and CFT share some commonalities. Both EFT and and submission (Gilbert, 2010). The incentive or drive system CFT are rooted in attachment theory with an overarching goal moves people toward goals and achievements and results in of activating the caregiving system (Gilbert, 2010; S. M. John- feelings of excitement. The soothing system (i.e., oxytocin– son, 2004). In EFT, interventions are used to activate the car- opiate system) brings a sense of calmness, contentment, and egiving system of partners, which increase the security of the

Downloaded from tfj.sagepub.com at University of Texas Libraries on June 3, 2016 350 The Family Journal: Counseling and Therapy for Couples and Families 23(4) attachment bond. For example, in a typical EFT enactment, teach shame-prone traumatized clients how they could relate one partner may be instructed to turn to the other and openly to themselves compassionately but instead model compassion express a particular emotional need—an expression that natu- and allow that corrective emotional experience to internalize rally activates the attachment caregiving system and elicits within the client over time. This key difference is why these compassion in most partners (S. M. Johnson, 2004). Signals authors suggest that CFT can enhance EFT with shame-prone of kindness and compassion from one partner naturally acti- couples effected by trauma. vate the attachment processes of feeling soothed and cared for To date, no research studies have included an integration of by the other partner (Gillath et al., 2005). Gilbert’s CFT EFT, self-compassion, or CFT. However, Beckerman and (2005) identifies attachment systems of caring as one of the Sarracco (2011) explored the use of mindfulness, one of the two sources of altruism that underlie compassion. The first core components of self-compassion, as a way to enhance EFT. is kin altruism and evolved to careforthosewhoarerelated The researchers demonstrated the use of mindfulness practice to each other. The second is a desire for justice and morality within the framework of EFT using the case study of a wife within relationships and is geared toward the wider context of suffering from depression. The researchers concluded that both social relationships. Focusing specifically on self- the couple and the therapist were better able to access underly- compassion, though it is a largely intrapsychic process, has ing attachment-related emotions and concerns. The couple interpersonal impact. Self-compassion makes a person more reported significant gains, including improvements in the available and open to their partner’s attachment. The process wife’s level of depression and a reduction in marital conflicts. of self-compassion when observed by a partner serves two The couple attributed their gains to their mindfulness practice, important functions. It not only serves as a model of self- and these gains were maintained at a 6-month follow-up. acceptance but also reassures the partner that one is ready and willing to offer compassion and acceptance if shown vulnerability. Clinical Integration Furthermore, EFT and CFT emphasize the role of the thera- Therapists can use self-compassion principles and practices pist as an important attachment figure that offers a corrective both from Neff’s self-compassion research (2003a, 2003b) and emotional experience for clients (Gilbert, 2010; S. M. Johnson, Gilbert’s (2010) CFT to enhance EFT. Self-compassion-based 2004). Therapists in both approaches use depathologizing fra- interventions may be used in EFT to help clients downregulate meworks and interventions such as validation, reflection, and clients’ triggered threat systems and help the clients move into normalizing while using tone and pace of voice to help create their affiliative soothing system (Gilbert, 2005). Once in their safety for clients to explore their emotional experiences. In soothing system and experiencing subsequent feelings of calm EFT, the focus is on present-moment process and bringing and safety, clients would be more apt to take in information, awareness to client’s experiences, which is consistent with respond empathically with themselves and their partner, and Neff’s (2003a) and Gilbert’s (2010) use of mindfulness. The engage more freely in the overall therapeutic process (Gilbert, EFT and CFT therapist seeks to focus on the here-and-now 2010; Longe et al., 2010). as a way to expand client’s experiences and integrate hidden As noted earlier, self-compassion interventions have the parts of their psyche while helping them create new meanings capacity to improve EFT outcomes when utilized with clients (Gilbert, 2010; S. M. Johnson, 2004). EFT’s integration with and by therapists to regulate their own experiences of shame. Buddhist thought, particularly the use of mindfulness, has been Subsequently, several examples of the use of self-compassion explored elsewhere (S. M. Johnson, Faller, Bradley, & Ama- interventions with clients are described, followed by a brief dis- deo, 2011). cussion of specific exercises for therapists. Of course, these theories also offer points of divergence. Although teaching self-compassion interventions and skills can be done in a bottom-up experiential manner (Gilbert, 2005, Clinical Interventions 2009), there is still a didactic component that falls outside the Achieving Stage I de-escalation can be difficult with trauma- EFT model, as it is primarily a present process and experiential tized couples stuck in negative interactions because one or both approach that does not teach skills explicitly (S. M. Johnson, partners are prone to being flooded by trauma symptoms such 2004; S. M. Johnson & Faller, 2011). In EFT, couples naturally as debilitating shame or other secondary emotions (S. M. John- gain emotional regulation skills such as mindfulness and the son, 2002; Macintosh & Johnson, 2008). An important clinical ability to attune to their partner’s emotions and needs as well implication of enhancing EFT with a self-compassion compo- as their own over the course of therapy with a collaborative and nent is using self-compassion work to help escalated partners experiential therapist (S. M. Johnson, 2004). In other words, self-soothe in Stage I of EFT. Although S. M. Johnson unlike CFT therapists, it is not a common practice for EFT (2004) focused more explicitly on couples coregulating one therapists to explicitly teach clients self-regulation skills such another, Greenberg and Goldman (2008) emphasized self- as mindful breathing (MB), mindfulness meditations, and com- regulation and self-soothing strategies to help couples avoid passionate imagery exercises in session or ask them to do them negative interactions. Therapists typically act as coregulators as homework. Further, an EFT therapist would not explicitly of both partners’ emotional experiences in Stage I of EFT

Downloaded from tfj.sagepub.com at University of Texas Libraries on June 3, 2016 Karris and Caldwell 351 because partners are escalated and cannot soothe each other constrictive threat mind to help soothe and slow them down, (S. M. Johnson, 2004). Therapists can help coregulate partners enabling them to respond from a calm and compassionate state. by bringing self-compassion work into therapy via using self- For example, after a few sessions with a couple, the therapist compassion psychoeducation, imagery work, breathwork, and could help clients distinguish between the threat and compas- meditation to help emotionally flooded partners self-soothe. sionate mind by saying in a slow, compassionate tone, ‘‘Mary, The ability to self-soothe through self-compassion inter- I noticed your face turned flush and you turned away and shut ventions could enhance EFT by allowing the traumatized or down when Jim was talking about how you could be demand- shame-filled person to achieve a calmer state in session and ing at times. I know how difficult it must be for you to hear that experience a greater ability to engage in the therapeutic from someone who is so important to you. It seems like you are process with his or her partner. Couples who learn self- in the threat mind right now, is that right?’’ In another session, compassion interventions have the additional benefit of gain- the therapist says, ‘‘Mary, I noticed one part of you was tender ing skills that they could then use at home to self-soothe if and kind with Jim about his feeling inadequate, and another they become triggered and dysregulated, and their partners are part of you wants to turn away and beat yourself up for not unable to comfort them. Couples who are able to learn self- showing him enough love. Can you allow that shameful part compassion interventions in session and practice them at of you to step to the side for one moment, and could you stay home may move through Stage I de-escalation more quickly with that compassionate part of you? Could you take a breath and then continue to Stage II, which involves inviting couples and respond from your compassionate mind?’’ Psychoeduca- to achieve a greater degree of coregulation and a more secure tion, when done in an empathic and compassionate manner, emotional bond, and can heal wounded areas of the psyche teaches clients about affective states they may experience in (S. M. Johnson, 2002, 2004). Indeed, S. M. Johnson (2002) therapy and validates and normalizes their emotional experi- noted, ‘‘To be seen and understood by the one we love best ences as they occur (Leahy, 2002). Once the coregulatory func- may be the most powerful weapon against shame’’ (p. 60). tion of the attuned therapist is achieved, the client is then able The best-supported interventions for accomplishing this to respond from a more calm and compassionate mind. include psychoeducation, imagery, and MB. Additionally, CFT therapists use psychoeducation to explain to clients that much of what goes on in their brains is not their fault, which helps externalize their debilitating symptoms, Psychoeducation. Psychoeducation is an important early inter- thereby allowing them to see themselves in a more compassionate vention in CFT (Gilbert, 2010) with individuals and groups and way (Gilbert, 2010). CFT therapists also give clients psychoedu- also in EFT with couples affected by trauma (S. M. Johnson, cation about the difference between guilt, shame, and other con- 2002). Since trauma symptoms can feel unpredictable and stricting emotions as a way to organize and normalize their overwhelming, the ability to make sense of clients’ experiences experiences (Gilbert, 2010). The use of CFT’s simple terms and can be beneficial in the beginning stages of trauma work diagrams of the two-minds and its evolutionary explanation of (Allen, 2001). Neff’s (2012) research regarding self- shame and other emotions could be incorporated into EFT with compassion can provide valuable psychoeducation to clients. its basis in attachment theory, ultimately providing a nuanced Gilbert’s (2010) theory and model of psychotherapy can also psychoeducation for clients in the beginning stages of therapy. enhance EFT by providing therapists with a nuanced depathologizing perspective on trauma, shame, and the brain. Imagery. Compassion-focused imagery (CFI) exercises are For example, in the early phase of treatment, CFT therapists practical self-compassion interventions EFT therapists could use psychoeducation and diagrams to inform clients about the use in their work with traumatized couples. CFI is one of the ‘‘threat mind’’ and ‘‘compassionate mind,’’ which are related most important interventions of CFT (Gilbert, 2009) and has to the ‘‘threat’’ and ‘‘soothing’’ affect regulation systems, the potential to act as a catalyst to stimulate the soothing affect respectively (Depue & Morrone-Strupinsky, 2005; Gilbert, system, decrease cortisol, and bring a sense of subjective 2005). Therapists inform their clients how the threat mind and calm (Gilbert, 2009; Rockliff, Gilbert, McEwan, Lightman, compassionate mind evolved with their unique set of thoughts, & Glover, 2008). Therapists have used imagery work as an behaviors, feelings, images, focus, and fantasies (Gilbert, 2010). intervention for many psychological issues such as trauma The threat mind is protective and geared toward fighting, flee- (Arntz, Sofi, & Breukelen, 2013; Barry, 2012; Shachar, ing, freezing, and triggers painful thoughts, memories, and fan- 2010; Van der Hart, 2012), adult relationship problems (Barry, tasies activating emotions such as anger, anxiety, or disgust 2012), self-criticism, and shame (Gilbert & Irons, 2004; (Gilbert, 2010). The compassionate mind, which can activate the Gilbert & Procter, 2006). soothing affect system, is related to feelings of warmth, safety, S. M. Johnson (2002) suggested the use of ‘‘safety nets’’ in calm, and soothing. It is also related to the motivation to alleviate Stage I of EFT to manage overwhelming emotional states or suffering and to the tendency of having tender and compassio- maladaptive behaviors that can be detrimental to traumatized nate thoughts and memories (Gilbert, 2005). EFT therapists couples. We suggest therapists can use CFI interventions as could use CFT-based psychoeducation in the beginning of treat- safety nets in Stage I of EFT and as needed to help manage ment to help clients become more mindful when in the moments of hypervigilance and dysregulation, which according

Downloaded from tfj.sagepub.com at University of Texas Libraries on June 3, 2016 352 The Family Journal: Counseling and Therapy for Couples and Families 23(4) to research has on occasion ‘‘derailed’’ the EFT process (Macin- mindfulness as ‘‘moment-to-moment awareness’’ (p.2). Ger- tosh & Johnson, 2008). Part of the reason that the therapeutic mer (2005) added acceptance to the definition of mindfulness process can be halted is because couples whose threat systems and defined mindfulness as ‘‘awareness of present experience are intensely activated no longer have access to their prefrontal with acceptance’’ (p. 7). MB is a way of paying attention to cortex’s rational faculties and become subject to the amygdala’s one’s breath in the present moment with acceptance and find- primitive self-protective processes (Arnsten, 2009; Thayer, ing one’s soothing rhythm (Gilbert, 2009). It is a way of noti- Hansen, Saus-Rose & Johnsen, 2009). Gottman (2009) listed cing in the present moment the many experiences associated self-soothing imagery as one of many interventions couples can with breathing, such as the breath going in through the nose use when their fight-or-flight response system engages, they or mouth, noticing the diaphragm lifting and falling, noticing become flooded and are unable to engage in relational intimacy the coolness or warmness of the breath, and so forth. If a part- or effective dialogue. The use of CFI can allow couples to de- ner is distracted or overtaken by painful thoughts or feelings, he escalate, activate their soothing systems, and reengage the ther- or she can compassionately refocus on his or her breath without apeutic process with greater ease. judgment of the stressful dynamics at hand. One example of a CFI intervention for shame-prone trauma- The practice of MB is associated with less rumination, neg- tized partners who are unable to self-soothe and self-regulate is ative thinking, brooding, and depression (Burg & Michalak, having them create and engage with an ideal compassionate 2011). Feldman, Greeson, and Senville (2010) showed that image or perfect nurturer (Gilbert, 2009; Lee, 2005). Compassio- MB was able to reduce emotional arousal and help partici- nate image scripts for individuals affected by trauma are found in pants view their internal experiences with greater objectivity. the CFT literature (e.g., Gilbert, 2010; Lee, 2012). The therapist Mindful breathing was also shown to offer psychological ben- would help the traumatized partner or partners create an ideal efits over and above progressive muscle relaxation exercises image that embodies wisdom, strength, warmth, and a nonjudg- and loving–kindness meditations. Neff and Germer (2013) mental compassionate presence. The perfect nurturer could be use an MB practice with participants in their Mindful Self- a human, animal, deity, or whatever the partner wishes. Ideally, Compassion 8-week self-compassion training program. Gil- it should embody the preferred physical and sensory characteris- bert and Procter (2006) used an MB practice with his group- tics (smells, voice tones, somatic expressions, etc.) the partner based therapy program called Compassion Mind Training, desires. Partners on the avoidant attachment spectrum and those which is aimed toward helping those who deal with intense prone to shame and self-criticism might not be able to have con- shame and self-criticism. tact with safe attachment inner working models and therefore EFT therapists can use MB when working with trauma, find some imagery work difficult (Gilbert, Baldwin, Irons, Bac- especially in Stage I, where de-escalation and loosening of cus, & Palmer, 2006; Mikulincer, Gillath, & Shaver, 2002; Rock- rigid interactional patterns can be difficult. Because of trauma liff et al., 2008). Therefore, creating their own perfect nurturer partners’ difficulty regulating emotions and hypervigilance could fill in these gaps and also create a retrieval advantage over to threat cues, keeping them in the ‘‘window of tolerance’’ harsh images and memories from the past (Lee, 2005). (Siegel, 1999, p. 253) where there is access to higher brain pro- Having the partner create and engage with a compassionate cesses and ability to integrate experience is important. Becker- perfect nurturer in Stage I of EFT could be vital when a person man and Sarracco (2011) showed through a case study that is unable to soothe his or her dysregulated partner. The compas- using a deep breathing mindfulness exercise was efficacious sionate perfect nurturer over time could function as an inter- in helping a couple diffuse an escalating conflict in an emotion- nalized attachment figure that is able to generate warmth, ally focused couples session. MB and CFI can be done at compassion, and stability in times of disruptive dysregulation, home and at the start of therapy sessions to help couples feel enabling the couple to engage fully in the EFT process as well grounded and at any point in the session when partners are trig- as providing a comforting image they could engage with at gered and become hyperaroused past the window of tolerance. home. Although extremely rare in the EFT literature, S. M. Integrating CFT with EFT is not meant to be a clinical path Johnson (2004) demonstrated the use of compassionate ima- in which therapists teach compassion-focused self-regulation gery with a wife who was prone to self-judgment and had dif- skills and isolate the traumatized partner or partners, essentially ficulty trusting her husband. Instead of needing to create a performing individual therapy. The goal is for emotionally perfect nurturer, the therapist used ‘‘her angel’’ (p. 315), which reactive clients who are overtaken by constricting emotions was the wife’s grandmother. Experiential engagement with the such as shame, fear, and anger to learn skills to help reduce internalized image of her grandmother became a turning point flooding and continue toward the EFT goal of coregulation and in her ability to soften and move closer to her husband. creating a secure bond (S. M. Johnson, 2004). The teaching and use of self-regulation skills within couples’ therapy is a com- MB. In addition to imagery, MB is also an effective tool EFT mon practice. For example, Gottman (1999a) listed self- therapists can use for de-escalation. MB, although not exclu- soothing imagery and breathing practices as one of many sive to self-compassion work, is a self-compassion–focused intervention couples can use when they are flooded by intervention used in conjunction with many compassion- their triggered fight-or-flight response system and are unable focused exercises (Gilbert, 2009). Kabat-Zinn (1999) defined to engage in the therapeutic process. Atkinson’s 2015

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Pragmatic-Experiential Therapy for Couples (PET-C) meditation and used when a therapist becomes dysregulated, approach to couple’s therapy employs mindfulness-based fearful, or unsure of what to do in a session with an esca- practices to help clients slow down, regulate their emotions, lated couple overtaken by trauma. The therapist could be present, and listen to the deeper messages their partners are pause, take a deep breath, and use mindfulness to become conveying. Additionally, Dialectical Behavior Therapy for aware of his or her internal emotional process. Being more couples is an approach that centers around the idea that highly mindful and present with his or her experience could help aroused, negative emotion keeps couples in conflict, and that the therapist remember that all therapists struggle at times learning skills to downregulate is essential for effective com- in session, especially with dysregulated couples. Reminding munication and a satisfying relationship (Fruzzetti, 2006; oneself of the universality of struggling emotionally and Kirby & Baucom, 2007). Enhancing EFT with self- cognitively as therapists exemplifies the theme of common compassion skills, principles, and practices follows the path humanity, which is another component of self-compassion. of other models that teach self-regulation skills to clients with The dysregulated therapist could then extend kindness to the overall goal of achieving a more secure bond. The goal of himself or herself instead of shame and judgment, which self-regulation toward coregulation would be made explicit to is the third component of self-compassion. The therapist clients when teaching any self-compassion skills. could say to himself or herself, ‘‘May I be compassionate There are additional benefits of learning self-compassion to myself in this moment’’ or ‘‘May I be free from my harsh practices in EFT sessions. For example, these skills could be critic and accept myself as I am.’’ As dysregulated thera- used at home when trauma symptoms arise and partners pists engage in Neff’s trinity of self-soothing, they can reg- are unavailable or when partners are at home but not acting ulate their fear, become more present, and continue the as a safe attachment figure due to the negative cycle. Self- therapeutic process. regulation is difficult under many circumstances including intense negative emotions (Baumeister & Heatherton, 1996) and positive affiliative emotions (Gilbert, 2010); however, Conclusion through repeated practice with a warm, empathic, and compas- Therapists can potentially use self-compassion and its various sionate therapist consolidation of compassion skills can be practices and interventions to enhance EFT with shame-prone achieved (Gilbert, 2010). Clients are encouraged to practice couples struggling with the aftermath of trauma. Self- these skills when it is easy and they are not in their threat mind. compassion, through Neff’s research and Gilbert’s cohesive Finally, many couples affected by trauma have invariably been model of therapy, has the potential to help dysregulated thera- in individual therapy or are in individual and couples’ therapy pists maintain an attuned, compassionate and calm presence concurrently (S. M. Johnson, 2002). Individual therapy with while moving delicately through the EFT process with trauma- trauma survivors typically includes some form of self- tized couples. Although moving to EFT Stage II coregulation is regulation skills to downregulate overwhelming affect (Briere the best antidote to a partner overtaken by trauma and shame & Scott, 2014). EFT therapists can engage in collaborative care (S. M. Johnson, 2002), it is not easily achieved when trauma- by solidifying the self-compassion–based self-regulation skills tized partners can get stuck in Stage I due to seeing his or her clients have been learning in their individual therapy if they partner as the enemy and high dysregulation. Neff’s (2003a) have been practicing these skills. Regardless, practicing ima- self-compassion and interrelated components of self- gery and breathing serves to enhance the overwhelmed partners kindness, common humanity, and mindfulness as well as Gil- in home, work, and therapy settings and allows for them to bert’s (2009) compassion-focused interventions and frame- overcome previously learned deficits in emotion regulation. work could contribute to self-regulation strategies in the form of psychoeducation, imagery work, MB practices, and medita- Brief Self-Compassion Intervention for Therapists tions that could help both the couple and the therapist when they become dysregulated. As the partners in a trauma couple Clients, of course, are not the only ones in therapy who can are able to experience a calmer state, they can move along the become overwhelmed with trauma work. In her seminal work EFT stages toward a more coregulatory, safe, and secure bond on EFT and trauma, S. M. Johnson (2002) warned that having with greater ease. When dysregulated therapists use self- a majority of a therapist’s practice focused on couples with compassion in and out of session, they can achieve a more relationship distress and trauma in particular ‘‘renders one vul- calm, mindful, and compassionate state that enables them to nerable to burnout’’ (p. 204). The best strategy for struggling become a more present and compassionately attuned therapist therapists is to seek a safe haven in the form of trusted col- who can better model and embody the skills they are trying leagues and supervisors (S. M. Johnson, 2002). Self- to impart to their clients. compassion could also be used in EFT with traumatized couples as a way to manage the therapist’s own dysregulation in therapy, thus being able to be more effective for the couple. Declaration of Conflicting Interests For example, the components of self-compassion as The author(s) declared no potential conflicts of interest with respect to defined by Neff (2003a) could be turned into a brief silent the research, authorship, and/or publication of this article.

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